The APPLE Tree programme: Active Prevention in People at risk of dementia through Lifestyle, bEhaviour change and Technology to build REsiliEnce-randomised controlled trial.

BACKGROUND: Large-scale trials of multidomain interventions show that modifying lifestyle and psychological risk factors can slow cognitive decline. We aim to determine if a lower intensity, personally tailored secondary dementia prevention programme for older people with subjective or mild objective memory decline, informed by behaviour change theory, reduces cognitive decline over 2 years. METHODS: A multi-site, single-blind randomised controlled trial recruiting 704 older adults at high dementia risk due to mild cognitive impairment (MCI) or subjective cognitive decline (SCD). Participants are randomised using 1:1 allocation ratio to the APPLE Tree intervention versus control arm (dementia prevention information), stratified by site. The intervention explores and implements strategies to promote healthy lifestyle, increase pleasurable activities and social connections and improve long-term condition self-management. Two facilitators trained and supervised by a clinical psychologist deliver ten, 1-h group video call sessions over 6 months (approximately every fortnight), video-call 'tea breaks' (less structured, facilitated social sessions) in intervening weeks and individual goal-setting phone calls every 2 weeks. From 6 to 12 months, participants meet monthly for 'tea breaks', with those not attending receiving monthly goal-setting phone calls. Participants receive a food delivery, pedometer and website access to cognitive training and information about lifestyle modification. Follow-ups for all outcome measures are at 12 and 24 months. The primary outcome is cognition (Neuropsychological Test Battery (NTB) score) at 24 months. Secondary outcomes are quality of life, cost per quality-adjusted life year (QALY) and wellbeing and lifestyle factors the intervention targets (diet, vascular risk, body weight, activity, sleep, anxiety, depression, social networks and loneliness, alcohol intake and smoking). Participants from purposively selected sites participate in qualitative process evaluation interviews, which will be analysed using thematic analytic methods. DISCUSSION: If effective, the intervention design, involving remote delivery and non-clinical facilitators, would facilitate intervention roll-out to older people with memory concerns. TRIAL REGISTRATION: ISRCTN17325135 . Registration date 27 November 2019.

A realist evaluation of a collaborative model to support research co-production in long-term care settings in England: the ExCHANGE protocol.

BACKGROUND: Collaborative working between academic institutions and those who provide health and social care has been identified as integral in order to produce acceptable, relevant, and timely research, and for outputs to be useful and practical to implement. The ExCHANGE Collaboration aims to bring together researchers and people working, living in and visiting care homes to build capacity, share and mobilise knowledge, and identify key areas for future research. This paper describes an embedded, formative, realist and theory-driven evaluation which aims to gather information about how successful the ExCHANGE Collaboration is perceived to be in achieving its aims. An existing realist programme theory from the literature - Closer Collaboration - will be supplemented by two substantive theories: Co-production and Knowledge Brokering. This will result in an initial programme theory which will be tested by this formative evaluation to refine understanding of how the ExCHANGE Collaboration works. METHODS: The evaluation will employ mixed qualitative methods, including: analysis of documents such as feedback forms, Knowledge Broker journal/diary, event attendance records, risk and issues logs and other relevant paperwork gathered as part of project delivery; observations of events/activities; and interviews with care home providers and staff, care home residents, residents' family members, and researchers who are involved in the project (both project design/delivery, and also attendance or involvement in project activities/events). Framework Analysis will be used to interpret the data collected; analysis will be strategic, by focusing on particular key areas of importance in the developing theory of how the ExCHANGE Collaboration might achieve change. RESULTS: The results of this study are expected to be published in 2022. DISCUSSION: This evaluation will investigate how successful the ExCHANGE Collaboration is perceived to be in achieving its aims, in what way, in which contexts, and how this may differ for those involved. It will do this by testing an initial programme theory about how the collaboration works, for whom, under which circumstances, and in what way. Findings will be shared through written publication, an end of project learning event for those involved/interested in the project, and a lay summary to be made publically available.

Frailty: A cost incurred by reproduction?

Evolutionary theories of senescence, such as the 'disposable soma' theory, propose that natural selection trades late survival for early fecundity. 'Frailty', a multidimensional measure of health status, may help to better define the long-term consequences of reproduction. We examined the relationship between parity and later life frailty (as measured by the Frailty Index) in a sample of 3,534 adults aged 65 years and older who participated in the English Longitudinal Study of Ageing. We found that the most parous adults were the most frail and that the parity-frailty relationship was similar for both sexes. Whilst this study provided some evidence for a 'parity-frailty trade-off', there was little support for our hypothesis that the physiological costs of childbearing influence later life frailty. Rather, behavioural and social factors associated with rearing many children may have contributed to the development of frailty in both sexes.

Physiotherapy interventions for people with dementia and a hip fracture-a scoping review of the literature.

BACKGROUND: People with dementia are 2.7 times more likely to suffer a hip fracture than those without and their management is estimated to cost £0.92 billion per year. Yet there has been little focus on the effectiveness of interventions for this population. OBJECTIVE: The aim of this scoping review was to summarise the current available evidence for physiotherapy interventions for people with dementia who fracture their hip as well as to identify gaps in the literature that may require further research. DATA SOURCES: A systematic search of the following databases was undertaken-TRIP, CINAHL, Amed, Embase, PEDro, PsycINFO, Cochrane Library, Open Grey, Ethos, ISRCTN, Proquest, PROSPERO and UK Clinical Trials Gateway. STUDY SELECTION: Articles were included if they described an intervention which is considered within the scope of a physiotherapist and targeted those with both a hip fracture and dementia. SYNTHESIS METHODS: A narrative summary was then undertaken to describe the current state of the literature. RESULTS: Twenty six studies were included, of which thirteen were observational, six RCTs, two qualitative, two surveys and three systematic reviews. Only nine studies focused explicitly on physiotherapy interventions. CONCLUSION: The findings of this scoping review suggest there is limited evidence to guide physiotherapists in the management of people with dementia who fracture their hip. No evidence was found about perceptions or experiences of patients in this group or of the physiotherapists involved in their care. Further research is needed to develop and evaluate physiotherapy interventions for people with dementia who fracture their hip.

The experiences of physiotherapists treating people with dementia who fracture their hip.

BACKGROUND: It is estimated that people with dementia are approximately three times more likely to fracture their hip than sex and age matched controls. A report by the Chartered Society of Physiotherapy found that this population have poor access to rehabilitation as inpatients and in the community. A recent scoping review found a paucity of research in this area, indeed there has been no qualitative research undertaken with physiotherapists. In order to address this evidence gap, the aim of this current study was to explore the experiences of physiotherapists treating this population. METHODS: Semi-structured interviews with physiotherapists were undertaken in order to gain an in-depth understanding of how they manage this population. Physiotherapists were recruited from all over the UK and a purposive sampling strategy was employed. Thematic analysis was utilised. RESULTS: A total of 12 physiotherapists were interviewed, at which stage data saturation was reached as no new themes were emerging. The participants had a broad range of experience both in physical and mental health settings. Analysis identified three separate themes: challenges, "thinking outside the box" and realising potential. Physiotherapists felt significant pressures and challenges regarding many aspects of the management of this population. Mainly this was the result of pressures placed on them by guidelines and targets that may not be achievable or appropriate for those with dementia. The challenges and importance of risk taking was also highlighted for this population with an appreciation that standard treatment techniques may need adapting. "Rehabilitation potential" was highlighted as an important consideration, but challenging to determine. CONCLUSION: Interventions for the management of people with dementia and hip fracture need to consider that a traditional biomedical physiotherapy approach may not be the most appropriate approach to use with this population. However physiotherapists reported feeling pressurised to conform to a biomedical approach.

Variation in childhood and adolescent obesity prevalence defined by international and country-specific criteria in England and the United States.

OBJECTIVE: To compare childhood obesity prevalence in England and the United States using different criteria. SUBJECTS/METHODS: Participants included 2- to 17-year olds in the Health Survey for England (HSE, n=33 563) and the US National Health and Nutrition Examination Survey (NHANES, n=14 540) 1999 through 2006. Mean body mass index (BMI) and prevalence of obesity were compared using the UK 1990, US 2000 Centers for Disease Control and International Obesity Task Force (IOTF) criteria. RESULTS: English children at ages 2-5 years had a higher mean BMI than US children (mean difference (English minus US)=0.41 kg/m(2), 95% confidence intervals (CI) 0.31-0.52). At age ≥8 years, mean BMI was lower in England (for ages 8-11 years, mean difference = -1.00 kg/m(2), 95% CI -1.26 to -0.75; for ages 12-17 years, mean difference = -1.37 kg/m(2), 95% CI -1.59 to -1.14). The IOTF criteria produced the lowest estimates of obesity prevalence. The 2000 Centre for Disease Control and Prevention (CDC) criteria produced the highest estimates in younger children and the UK 1990 criteria produced the highest in adolescents. Children aged 2-5 years in England had higher prevalence of obesity than those in the United States when using the 2000 CDC and UK 1990 criteria. US adolescents had the highest prevalence of obesity by age group using each of the three criteria. CONCLUSION: The 2000 CDC and UK 1990 criteria give a higher prevalence of obesity in England than in the United States at ages 2-5 years; however, at age ≥8 years, the reverse is true. Estimates of childhood obesity prevalence rely on the criteria used, which has implications for surveillance and clinical practice.

Income and the midlife peak in common mental disorder prevalence.

BACKGROUND: The prevalence of psychological distress and common mental disorders has been shown to peak in midlife but analyses have ignored the association of poor material circumstances with prevalence. This study aimed to test the hypothesis that the midlife prevalence peak occurs only in lower-income households. METHOD: Pooled data were used from the annual Health Survey for England, a nationally representative cross-sectional study, on community-dwelling individuals aged ≥ 16 years from years 1997 to 2006 (n=100 457). 12-item General Health Questionnaire scores, reported mental illness diagnoses and receipt of relevant medication were assessed in relation to household income and age. Analyses were separated by gender and adjusted for age, ethnicity, smoking, social class, education and co-morbidities. RESULTS: Prevalence of psychological distress, diagnoses and treatments rose with age until early middle age and declined subsequently. In analyses conducted separately by income categories, this pattern was marked in low-income groups but absent in high-income groups. Income-related inequalities in the prevalence of psychological distress were greatest in midlife; for example, in men aged 45-54 years the odds ratio of receiving psychiatric medication in the lowest income group compared with the highest was 7.50 [95% confidence interval (CI) 4.24-13.27] and in women aged 45-54 years the odds ratio of reporting mental illness was 10.25 (95% CI 6.16-17.05). CONCLUSIONS: An increased prevalence of psychological distress, common mental disorder diagnoses and treatment in midlife is not a universal phenomenon but is found only in those in low-income households. This implies the phenomenon is not inevitable but is potentially manageable or preventable.

Serum albumin concentration and cognitive impairment.

Results from clinical samples suggest low serum albumin may be associated with cognitive impairment, though evidence from population-based studies is inconclusive. Participants were 1,752 adults (699 men and 1,053 women) aged 65 years and over from the Health Survey for England 2000, a nationally representative population-based study. Cognitive impairment was assessed using the Abbreviated Mental Test Score. The cross-sectional relation of serum albumin quartiles to cognitive impairment was modelled using logistic regression. Two hundred and twelve participants were cognitively impaired (68 men and 144 women). Odds ratios (95% confidence intervals) for cognitive impairment in the first (2.2-3.8 g/dl), second (3.9-4.0 g/dl), and third (4.1-4.3 g/dl) quartiles of serum albumin compared with the fourth (4.4-5.3 g/dl) were 2.5 (1.3-5.1), 1.7 (0.9-3.5), and 1.5 (0.7-2.9), after adjustment for age, sex, education and additional risk factors for cognitive impairment (p for linear trend = 0.002). A highly similar pattern of associations was observed for men and women. Our data provide new evidence to suggest that low serum albumin is independently associated with increased odds of cognitive impairment in the elderly population.

Neighbourhood deprivation and dental service use: a cross-sectional analysis of older people in England.

BACKGROUND: Appropriate dental care is an important part of maintaining good oral health. We examined the relationship between socioeconomic status, neighbourhood deprivation levels and older people's dental service use. METHODS: We used logistic regression analysis to assess the relationship between self-reported dental service use and neighbourhood deprivation, adjusting for individual socioeconomic and health factors, in individuals aged 65+ in the 2005 Health Survey for England (n = 4240). RESULTS: Among dentulous respondents, 69.9% reported attending for regular check-ups, 6.2% occasional check-ups, 18.4% only saw a dentist when in trouble and 5.6% never went to a dentist. In our adjusted model age, sex, region, education level, occupational social class, self-reported health and smoking status, but not degree of urbanization, were associated with use of dental services. Following adjustment for these other factors those living in the most deprived 20% of neighbourhoods, compared with those in the least deprived, had a relative risk ratio of 2.25 (95% confidence interval 1.59-3.17) of using dental services only when symptomatic, rather than going for regular or occasional check-ups. When alternative outcomes of reporting having recently seen a doctor or been a hospital inpatient were assessed these deprivation-related patterns in service use were not evident. CONCLUSION: Levels of neighbourhood deprivation are associated with the use of dental services by older people. Action is needed to ensure older people in deprived communities access appropriate and comprehensive dental services.